How to Appeal a Health Insurance Claim Denial

After trying to conceive on their own without success, a couple from outside Chicago wanted to use vitro fertilization, or IVF. Their insurance company refused to pay for the procedure, saying that IVF wasn’t medically necessary. The couple appealed the denial, only for the insurer to deny the claim again, this time arguing thatthe company had already paid for one round of IVF treatment, even though it hadn’t. Unsure of what to do next, the couple hired Gayle Byck to unravel the reasoning behind — and hopefully fight — their denied claim.

“I called and asked the insurer, ‘Could you tell me the date for the treatment?’” says Byck, who founded InTune Health Advocates, a private patient advocacy practice based in Deerfield, Illinois. “They kept me on hold for over an hour. They called me back the next day and agreed that my client had never had the procedure.”

With that, the couple’s insurer agreed to pay their IVF bill.

Appealing a denied insurance claim can be an aggravating, time-consuming process. To give yourself the best chance of winning an appeal, you’ll need to be persistent, know how your insurance plan works and be vigilant about noticing and correcting billing mistakes. With help from experts, we put together a primer on the appeals process.

Know your policy

Before you seek any kind of medical treatment, make an effort to understand what your insurance plan covers and what it doesn’t. It’s important to know if a provider is in-network, whether your plan requires you to meet a yearly deductible and what that amount is before your insurer will cover your care. Call the customer service number on your health insurance card and ask.

Once you know the ins and outs of your coverage, it will be easier to flag an unwarranted denial. “Remember, your insurance plan is a contract with your insurance company,” says Byck. “Really understand why they are denying it. Refer back to your policy so you can understand what your rights are.”

Craft your appeal

While patients often learn about claim denials after the fact, insurance companies may also deny coverage for a treatment beforehand, as with the Chicago couple’s IVF claim denial.

A claim might be denied for several reasons, says Caitlin Donovan, director of outreach and patient affairs for the National Patient Advocate Foundation, a group that helps people with chronic illness decipher denied health claims. Here are the most common scenarios:

1) A patient receives care in an inappropriate setting, such as by going to the ER for a sore throat.

2) A patient isn’t eligible for a medical benefit, i.e., their treatment isn’t deemed medically necessary. This tends to happen when a patient receives services for a diagnosis the physician failed to document.Say someone gets a headache, blacks out, hits their head and twists an ankle. A doctor orders CT scans and documents the reason, such as headache and head trauma. The physician also orders an X-ray for the twisted ankle but doesn’t document the reason. The insurer may approve the CT scan but deny the ankle X-ray as not medically necessary, since the supporting medical diagnoses didn’t mention or diagnose an ankle injury.

3) A patient doesn’t resolve a claim in time. Watch for deadlines: You have 180 days from the date of service to appeal a denial.The 180-day appeal window will be specified in an explanation of benefits form. Following any appointment or insured healthcare service (i.e., unless a patient self-pays for care), a patient will receive an EOB stating how much their insurance company paid for the treatment and how much they still owe. The deadline for an appeal is always based on the date of a treatment or medical visit — even when the EOB letter isn’t sent until weeks or months afterwards. When an insurance company denies a claim, the EOB will explain why and tell you how to file an appeal to counter the denial. “The EOB will tell you where to send any additional information, and it’s important to follow all the directions,” says Byck, adding that the insurance company will look for any reason to turn down an appeal.

Get your doctor on your side

“Once you have the exact reason the claim was denied, use that language to shape your own appeal,” Donovan says. “Think of it like a contract dispute and use facts, not emotions.”

If your insurer says that your treatment was not medically necessary, or that it’s considered experimental, go to your provider and ask them to help you prove its necessity, with documentation.

Always ask your provider to confirm the diagnostic code(s) they used for your diagnosis and treatment. On the off-chance they coded something incorrectly, they’ll need to resubmit the claim using the right code(s). If there were no coding mistakes, ask yourprovider to write a letter to your insurance company in support of your appeal. It’s helpful to have a physician endorse your appeal because it will be evaluated by the insurance company’s own healthcare providers, who are hired to review claims. “Sometimes a company’s provider is not a specialist in the area,” says Donovan. “I’ve heard patients say they need a certain neurological treatment, and the insurance provider reviewing it is an oncologist. It’s one more layer in why dealing with the healthcare system can be so frustrating.”

Do your own research

If you’re dealing with a denial from a private insurer, figure out if Medicare covers the treatment. (Donovan says a Google search should do the trick.) If the treatment is covered by Medicare, that means it’s considered the clinical “standard of care” and should be covered by most private insurers.

Another way to show that a treatment is considered medically necessary for a given diagnosis is to find medical journal articles that say the treatment is an accepted method of care. You can always ask your doctor’s office for help with this research. But if you want to do it on your own, stick to reputable, peer-reviewed journals (meaning those whose articles are evaluated by independent medical experts before publication). Two of the best known medical journals are The New England Journal of Medicine and the Journal of the American Medical Association. A comprehensive collection of peer-reviewed articles can be found on Pubmed, the National Institutes of Health’s database. You can also search for studies on Google Scholar.

“One way to determine the legitimacy of any journal, and thus the research inside, is to find the publication’s influence score,” Donovan says. (Influence score basically measures how often an article is cited in other reputable research.) “If an article is frequently cited, it should be considered a good source.”

Try again

If your appeal is denied, read your insurer’s explanation and try again. Then again, if necessary. “Our case managers are the best, and it still takes, on average, 22 calls for [an appeal to succeed],” Donovan says. “And we know it’s really frustrating for the patient to work through even one call.”

To appeal one of her own denials, Donovan talked to her physician’s office and learned that one of her claims had been coded incorrectly. She then spent time on the phone with her insurance company to make sure the code was fixed in its computer system. Then she waited: “I had the answer on the first day, and the claim took a year to resolve. It’s important to dot your I’s and cross your T’s.”

If a claim dispute drags on, you will likely start to receive bills from your provider requesting payment. In this situation, Donovan says, contact whoever is billing you and let them know you’re disputing the claim. If you do this, the billing company — which could be for a doctor’s office, a hospital or wherever you received treatment — should be willing to hold off looping in a collections agency, since they know you’re actively working with the insurance company to resolve payment.The last thing you want to deal with is the trouble of fighting an insurance claim while also battling a collection agency.

Don’t hesitate to push back

How often do medical bills contain errors, such as incorrect or incomplete codes, or wrong information about the patient or provider? Estimates vary widely; one 2017 report put the error rate between 30 percent and 90 percent. “People tend to be shy about pushing back on denials or challenging bills with errors, and they shouldn’t be,” says Donovan. “It’s important to get things right when medical issues and financial security overlap, especially if you are putting off an appointment or procedure over concern about how much it costs.”

Donovan recommends advocating for yourself as you would for a child: “It’s not unlikely that an insurance company is wrong. Obstacles will be thrown in your path. You have to have conviction.”

To beat an insurer at its own game, keep fighting. “Insurance companies are counting on attrition,” says Byck. “If you stick with it, your chance of success goes up.”

Read this next

For people with irritable bowel syndrome, it’s common to hear that symptoms such as cramping, alternating diarrhea and constipation, and bloating are “all in their head.” In the case of IBS, there’s actually some truth to this.

It’s not that their symptoms don’t exist. IBS is a very real disorder, and managing its physical toll often becomes an all-consuming effort. The litany of concerns that accompany so many activities — always scouting the closest bathroom, making sure you can reach it in time, farting in public — keeps many people with IBS from having a social life.

Yet according to some experts, IBS is not solely about what’s going on in the digestive system; rather, the brain exacerbates the condition. “IBS is a disorder of brain-gut dysregulation,” explains GI psychologist Sarah Kinsinger, who is also co-chair of the psychogastroenterology section of the Rome Foundation. Accordingly, addressing the “brain” side of IBS through cognitive behavioral therapy with a trained psychologist may help decrease both the anxiety that’s often associated with the disorder and its physical symptoms.

“CBT really should be the first-line treatment for people with IBS. It’s the treatment with by far the most empirical support, and when done well, it can be curative,” says Melissa Hunt, associate director of clinical training in the psychology department at the University of Pennsylvania.

In a series of trialspublished last year, researchers in the UK compared the standard treatment for IBS (typically diet and lifestyle modifications and/or medication) with eight sessions of CBT delivered over the phone or online. Before and after the trials, participants answered questionnaires designed to measure their anxiety, depression and ability to cope with their illness. Two years after the trials, 71 percent of the phone-CBT group and 63 percent of the online-CBT group reported clinically significant changes in their IBS symptoms. Meanwhile, less than half of the standard-treatment group reported such an improvement. Those who did CBT also exhibited lower levels of anxiety and depression and higher coping ability than other participants.

In an earlier meta-analysis (a study of studies), published in 2018 in the Journal of Gastrointestinal and Liver Diseases, a different team of researchers also found that CBT appeared to reduce both psychosocial distress and the severity of IBS symptoms, with a greater effect on the physical symptoms than on the mental ones.

Explainers

The brain-gut connection

How this happens is not completely clear at this point, but it’s believed to have something to do with how the gut and brain communicate.

“IBS is thought to be a disorder of centralized pain processing,” Hunt explains. “There is miscommunication between the pain centers in the brain and the nerves in the gut. In people with IBS, pain signaling gets inappropriately amplified.” Discomfort that wouldn’t even register in the majority of people feels like being stabbed in the gut to a person with IBS. “The best way to address that is to find ways to help reduce pain signaling, and that’s with a psychologist,” Hunt says.

CBT for IBS entails learning relaxation techniques, such as diaphragmatic breathing and progressive muscle relaxation, which help reduce the “volume” of the pain signals by activating the parasympathetic nervous system, i.e., the body’s “rest and digest” response. “This can also lead to increased blood flow and oxygen to the digestive system, which helps the GI tract to function in a more rhythmic way,” says Kinsinger, who is also an associate professor at Chicago’s Loyola University Medical Center.

CBT also involves thought restructuring. IBS can cause a cycle of worry: Worrying about symptoms leads to being hyperfocused on the slightest hint of any symptom, which increases anxiety, which aggravates symptoms. People with IBS also often catastrophize, meaning they assume the worst will happen (“If I have an accident at work, I’ll get fired and never get another job”), develop social anxiety and become withdrawn. CBT addresses these issues by shifting attention away from IBS symptoms and using exposure therapy to help people gradually engage in more activities outside their homes.

Additionally, using CBT, people with IBS learn to identify and change dysfunctional ways of thinking. For example, consider someone with school-aged children who asks their spouse to attend all school functions because they’re afraid of farting in a room with other parents, which would inevitably cause humiliation and might even make people think they’re disgusting A therapist might ask them how often they notice bodily noises from other people to help them realize that we’re a lot more cognizant of our own bodily functions than other people are. “In other words, we identify the catastrophic beliefs and then search for evidence supporting them or not,” Hunt says.

CBT is a skills-based, goal-oriented approach to treating mental disorders that emerged in the mid-20th century. All CBT programs share the same underlying goal of helping patients identify and modify negative or unhelpful thought patterns and behaviors. “It teaches patients techniques that they can then implement on their own.” says Kinsinger. “It can be done pretty efficiently, depending how motivated and receptive one is to learning these skills.” But over time, customized versions of CBT have been developed for specific conditions including insomnia, schizophrenia and IBS. Different versions of CBT use different techniques, such as role-playing, exposure therapy and relaxation exercises, and vary in length. On average, CBT for IBS lasts between 4 and 10 sessions in total.

Jeffrey Lackner, professor and chief of the division of behavioral medicine at the University at Buffalo, SUNY, says their program is structured like a course: “You learn a specific skill to manage your GI symptoms, process information differently or respond to stress in a less extreme way. Then you practice that skill in session before using it in the real world.” Often therapists also give patients homework to fine-tune the skills they learn. They come out of CBT with a toolbox of techniques to manage the day-to-day burden of IBS.

Some people with IBS do CBT on their own, using self-help books, online materials or apps without ever seeing a therapist. “Not many psychologists are trained to treat GI disorders specifically, so physicians don’t often have anyone to refer patients to,” Kinsinger says. The Rome Foundation trains psychologists and maintains a directory of gastrointestinal psychologists, but if someone can’t find a provider in their area, Hunt and Kinsinger recommend looking for a psychologist who’s trained in CBT and has experience treating chronic pain, panic disorders or anxiety.

Reducing sensations vs. reducing sensitivity

Not everyone is fully on board with CBT for IBS. One 2018 review study found “insufficient evidence to demonstrate the effectiveness of online CBT to manage mental and physical outcomes in gastrointestinal diseases” including IBS. A different 2018 review concluded that although psychological treatments for IBS appear to help in clinical trials, it’s unclear if they work in other settings and which treatments — such as CBT, mindfulness-based stress reduction and guided affective imagery — are most effective.

IBS is a complex problem, and some doctors prefer to integrate CBT with other treatments. But “by the time we see them,” Lackner says, “many of our patients have found that the medical treatments have not provided adequate symptom relief.”

Some IBS patients also find thetraditional approaches too hard to stick with. The most commonly prescribed treatment is a “low-FODMAP” diet, which requires giving up all dairy and legumes, plus many grains, fruits and vegetables. “Some trials show that even if the diet reduces or eliminates GI symptoms, it doesn’t improve quality of life because it’s crazy restrictive,” Lackner points out.

“With IBS, the nerve endings in the gut have become hypersensitized, and the brain magnifies those signals in the gut,” Hunt says. “The low-FODMAP diet tries to reduce the sensations, whereas CBT reduces the hypersensitivity. When you turn down the volume on the sensations, then you can eat whatever you want.”

Whether CBT helps with this brain-gut dysregulation, addresses distorted thinking and anxiety, or increases confidence in a person’s ability to manage gastrointestinal symptoms — or all of the above — it’s helped people with IBS resume parts of their life they’d put on hold.

Brittany Risher is a writer, editor and digital strategist specializing in health and lifestyle content. She's written for publications including Men's Health, Women's Health, Self and Yoga Journal.

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